Synopsis The passenger vessel NorwegianSky was on a voyage from Qubec, Quebec, to Halifax, Nova Scotia. The trip included a cruise of the Saguenay River. On its return to the mouth of the Saguenay, at about 1130 local time, whales were observed in the St.Lawrence River. To prolong the whale-watching activity, the vessel was turned around but ran aground on the Bancs de l'leRouge (RougeIslandBanks) before completing its manoeuvre. The vessel sustained substantial damage, but pollution was deemed minor. No injuries resulted from this occurrence. Ce rapport est galement disponible en franais. 1.0 Factual Information 1.1 Particulars of the Vessel 1.1.1 Description of the NorwegianSky The NorwegianSky is a 12-deck, 39000-tonne displacement passenger vessel that entered service in Dover, United Kingdom, on 09August1999. The vessel was on its maiden voyage to North America. The accommodation has a 2400-passenger and 750-crew member capacity. Life-saving appliances include, but are not limited to, lifeboats that can accommodate 2400persons and liferafts that can accommodate 1600persons. Six diesel-electric generators, producing 50700kW, supply energy to the hotel and propulsion systems. Two stern and three bow thrusters enable the vessel to move sideways when the vessel's forward speed does not exceed seven knots. Under way, two controllable-pitch propellers and two semi-balanced articulated flap rudders give exceptional vessel manoeuvrability at a service speed of 20knots. 1.2 History of the Voyage At 0030 eastern daylight time3, on 24September1999, the NorwegianSkydeparted Qubec, bound for Halifax, with 2712persons on board, including 1923passengers, and two Laurentian Pilotage Authority (LPA) pilots. Norwegian Cruise Line estimates that there were some 50different nationalities aboard and that the average age of the passengers was 63years. The ratio of passengers to crew members was2.4:1. The pilots estimated their arrival at Les Escoumins pilot station at about1300. The vessel sailed down the St.Lawrence River until it reached the entrance of the Saguenay River. The staff captain and pilot No1 were relieved by the master and pilot No2, respectively. At 0700, off Tadoussac, a naturalist boarded the vessel to act as a guide for the passengers during a scenic tour of the Saguenay River and whale-watching. The vessel returned to the St.Lawrence River. At 0855, the vessel reached Baie ternit and speed was reduced to approximately six knots to turn around off CapTrinit. After reporting to Marine Communications and Traffic Services (MCTS) Les Escoumins in Baieternit, the pilot confirmed to the master that there would be sufficient time for passengers to observe whales at the mouth of the fjord. The return voyage to the St.Lawrence River was uneventful. At 1107, the pilot reported to MCTS Les Escoumins that the vessel had reached the Pointe Noire / Tadoussac ferry crossing and that the passengers were about to begin whale-watching, before proceeding to the pilot station. The pilot noticed that excursion boats had grouped downriver from le Rouge and, according to the voyage plan, intended to join them. Visibility was good, with fair skies; winds were light and the seas calm. Under the supervision of the officer of the watch (OOW), a cadet plotted positions on the chart approximately every five minutes. Using the Pointe Noire range, the pilot conducted the vessel down the buoyed channel. At about 1120, near buoyS3, helm orders were given to steer a course of 115G (the gyrocompass error was negligible) for buoy K55. The pilot adjusted the radar variable-range marker to two nautical miles (nm) and asked the master to gradually reduce the vessel's speed. The master moved the speed levers and oversaw progress of the vessel by visual observation. Near the Bancs de l'le Rouge (Rouge Island Banks), at about 1133, the pilot noticed that the target of Haut-fond Prince (Prince Shoal) light was nearing the variable-range marker and that whales were now grouped downriver of buoy K55. Consequently, he ordered the helmsman to turn the helm 20 to port to head toward Les Escoumins pilot station. At about 1141, the vessel settled on a course of approximately 030T, heading toward the pilot station. At approximately 1148, the pilot realized that the whales were now abaft the port beam and, therefore, ordered 20 port helm (SeeAppendixA). Because some passengers had not seen the whales, a discussion took place on the bridge between the master, the pilot and the cruise director; it was decided that the vessel would remain a little longer in the area. During this discussion, the vessel had continued to fall off to port. Figure1. Approximate position of grounding At 1154, the vessel was now headed toward the Saguenay River, stemming the tide and no longer making way. The master and the pilot agreed that there was sufficient time to turn the vessel round and still be on schedule at the pilot station. Since whales were now off the port quarter, the pilot decided to turn the vessel to port. At 1156, the pitch of the propellers was increased and the vessel started to swing to port. There was no commercial traffic that could impede the NorwegianSky's passage in the area. The cadet continued to plot the vessel's position, while the pilot monitored the radar with the same variable-range marker setting. At 1158, the vessel's heading continued to fall off to port and was now heading toward buoy K55. At 1200, the helm was turned to midship, and the propeller pitch setting was reduced from approximately half to one third. After plotting the noon position, the cadet informed the master that the vessel was nearing the shoal near buoyK55. When the master expressed concern that the vessel was coming too close to the shoal, the pilot assured the master that the situation was under control. The pilot believed the vessel to be some four cables downriver of buoy K55 and the flood tide to be setting 210T at some two to three knots. At 1202, the master increased the pitch on the starboard propeller from 31%to48%, and the rate of turn to port gradually increased. At 1203, the pilot asked the master to increase speed and ordered the helm hard-a-port. The master advised him that hard-over helm would swing the stern out and that less helm action was recommended. As a result, an exchange took place concerning the helm and the speed but the helm was kept at hard-a-port. By 1204, with the heading about 076G and decreasing, the rate of turn had increased to 47.1 per minute. The vessel's stern made bottom contact with the shoal. The vessel slowed and the stern came to rest on the Bancs de l'le Rouge. At 1206, the vessel was aground, listing 5.2 to port, heading 074G, in position 4805.8'N, 06933.5'W. The electronic chart system (ECS) showed a speed of zero knots at1206.52 (SeeAppendixB). Figure2. Track of the NorwegianSky recorded by the ECS on board indicating the waypoints with their time stamps(UTC)(Section of ENC Chart# CHS 1203) 1.2.1 Events Following the Grounding Emergency procedures were initiated before the vessel fully came to rest. At 1205, the 8-12 OOW activated controls to close the watertight doors and splash doors.4 The staff captain and the chief officer, who felt the impact, rushed to the bridge to assist the master. At 1207, following the master's orders, the 12-4 OOW broadcast the emergency call, code delta5 D, on the public announcement system. At 1208, the general alarm was sounded on the ship's whistle. Then, on the public announcement system, the master ordered passengers to go to their assembly stations and crew to provide assistance. Meanwhile, the pilot reported the grounding to MCTS Les Escoumins. Navigation personnel followed the Norwegian Cruise Line Contingency and Crisis Plan. The port and starboard lifeboats were reported ready for embarkation at 1219 and 1228, respectively. Tank and void space soundings were taken. An ingress of water was found in three compartments. At 1242, the master apprised MCTS Les Escoumins of the situation and was advised that tug assistance had been sought. The Canadian Coast Guard Ship (CCGS) IsleRouge was requested to push on the starboard quarter to counteract the force exerted by the flood tide. After determining that it was safe to refloat the vessel on the rising tide, ballast was redistributed. With the assistance of the tug Techno Venture and the CCGS IsleRouge, the NorwegianSky was refloated, some three hours after grounding, at 1515. At approximately 1240 on 25September, the NorwegianSky weighed anchor, bound for dry dock at the port of Qubec. 1.3 Search and Rescue Operations 1.3.1 Marine Rescue Sub-Centre Operations After reporting the grounding to MCTS Les Escoumins, the Marine Rescue Sub-Centre (MRSC) set in motion its search and rescue (SAR) operations at 1208. The CCGS IsleRougewas promptly tasked and arrived on scene. Depth soundings were taken in the area of the grounding. The NorwegianSky's starboard side was firmly aground. At 1237, the two Pointe Noire / Tadoussac ferries and the three Les Escoumins pilot boats were placed on standby in case passengers were to be evacuated. At 1242, the master appraised MCTS Les Escoumins of the situation and was advised that tug assistance had been sought. A total of two Canadian Coast Guard (CCG) surface craft, three aircraft, two ferries, one commercial vessel, one tug, two service boats, and seven excursion boats were placed on standby for a rescue operation. Once the vessel was refloated, the crew informed the MRSC in Qubec that evacuation was no longer necessary. At 1541, the standby rescue craft were stood down. Subsequently, the NorwegianSkyproceeded across the river and anchored off le aux Basques anchorage. The CCGS Tracy was tasked and stood by the passenger vessel during damage assessment. 1.3.2 Injuries to Persons 1.4 Damage to the Environment Two perforated fuel oil tanks had been emptied before the grounding. Nevertheless, at 1635, approximately one hour after refloating the vessel, the pollution patrol aircraft GC300 observed pollution. The quantity released was deemed minor. 1.5 Bridge Team Certification and Experience 1.5.1 Navigation Personnel The manufacturer of the vessel's integrated navigation system (INS) had classroom and simulator training available to purchasers. Some cruise lines, including Norwegian Cruise Line, had sent its complement of officers to attend an awareness training session. There are no procedures to determine the proficiency of officers who operate the automated navigation system. The master held a Master Mariner Certificate of Competency issued by the Bahamas in1997, and a Master Deck Officer Class1 Certificate of Competency issued by Norway in1971. He had some 41years' sea service, which included serving as master since1972. He had taken command of the NorwegianSkyon 01July1999. As part of his continued proficiency training, in1999 he had taken an INS course that included an overview of electronic chart system (ECS) equipment.6 The first officer (the 8-12 OOW who had remained on duty after the end of his watch until the time of the occurrence) held a Deck Officer Class4 Certificate of Competency issued by Norway in1995 and an equivalent certificate issued by the Bahamas in1997. He had some 8years' sea service and, in1998, had begun serving as OOW. As part of his continued proficiency training, in1999, he took an INS course that included an overview of ECS equipment. The quartermaster on duty held a Deck Watch Navigation Certificate of Competency issued by the Philippines in1998. He had some three years' sea service, some of which was acquired on board the passenger vessel Norway. The cadet on duty had attended a maritime academy. He had acquired experience since1998 on fishing vessels and ferries. 1.5.2 Pilot on Duty The pilot on duty at the time of the occurrence held a First Mate Home Trade Certificate of Competency issued by Canada in1962. He also held a Class A Pilot Licence issued by the LPA in1975. He had some 41years' service, of which some 32years was acquired as a licensed pilot. As part of his continued proficiency training, in1987 and in1994, he received ship-handling training in France. However, the pilot had not acquired ship-handling expertise for vessels like the NorwegianSky. It was not until1996 that the training facility, where the pilot attended his training, added a model ship fitted with a flap-rudder reproducing ship-handling characteristics similar to the NorwegianSky. Under the pilotage services contract between the LPA and the Corporation des pilotes du Bas Saint-Laurent,7 ClassA pilots are required to acquire ship-handling training at an LPA-approved training centre, and adhere to a continued proficiency training program. 1.6 Weather, Current, and Geographical Information 1.6.1 Weather Visibility was clear, with partly cloudy skies and northwest winds at some 13knots. The air temperature was 15C. The SAR vessel CCGS IsleRougerecorded a water temperature of 5C. 1.6.2 Current Tidal information for the area at the mouth of the Saguenay River on the St.Lawrence River is contained in the Canadian Tide and Current Tables, volume3. Tidal differences are referenced to the port of Pointe-au-Pre and the secondary port of le Verte. On 24September2002, low water was predicted at 0904, with a height of 0.7m above chart datum, and high water at 1505, with a height of 3.7m above chart datum. The current was flooding at the time of the occurrence. According to the Fisheries and Oceans Canada publication, Atlas of Tidal Currents, two to three hours before high tide at Pointe-au-Pre, the current vector on the northern edge of the Bancs de l'le Rouge indicates a speed of one knot and a direction of approximately 180T. Those parameters are based on average weather conditions. Nevertheless, when the water level reading recorded by the Rimouski-Est tide gauge was extrapolated to Tadoussac, it was found to be 0.36m above the tide prediction. Researchers at the Maurice-Lamontagne Institute (Marine Sciences Research Centre) indicated that this water level increase might have augmented the intensity of the tide off the Bancs de l'le Rouge. 1.6.3 Geographical Information The Saguenay-St.Lawrence Marine Park is committed to the protection and development of marine resources and covers the northern half of the St.Lawrence estuary. It stretches from LesEscoumins wharf to GrosCap l'Aigle.8 From May to October each year, there is a large concentration of cetaceans in the area, especially between Grandes Bergeronnes and Tadoussac. Whale-watching is not always carried out in the same zones, because whales migrate to different feeding zones in the park. Three zones have been identified as having a greater concentration of marine mammals: Zone No1, off le Rouge; Zone No2, off Pointe la Carriole; and Zone No3, off GrandesBergeronnes. Figure3. Marine mammal feeding zones in Saguenay-St.Lawrence Marine Park To harmonize all marine mammal-watching activities in accordance with existing regulations, government departments and industry developed a code of ethics to set rules of conduct that apply to all commercial and recreational air- and water-borne craft. The code limits how closely the mammals may be approached. The Bancs de l'le Rouge form an extensive shoal area lying in the middle of the St. Lawrence River. This obstruction divides the river into two channels: north and south. le Rouge, with an elevation of 5.2m, is the summit of the banks of the same name. The low and sandy island has a lighthouse, two towers, and a few buildings. The approximate layout of the west and northwest banks off le Rouge lie respectively along position lines 190-010 and 240-060. Aids to navigation were not reported out of position in the le Rouge sector. BuoysK55 andK51 indicate, respectively, the northwest and northeast extremities of the Bancs de l'le Rouge. PointeNoire leading lights serve as a guide to vessels proceeding in the channel at the mouth of the Saguenay River. 1.7 Vessel Information 1.7.1 Certification The NorwegianSky was crewed, certified, and equipped in accordance with existing regulations. Although the complement of Norwegian officers and international service staff exceeded the 750-person complement capacity, the total number of persons aboard did not exceed the vessel's overall capacity of 3150persons. 1.7.2 Damage While aground, an ingress of water was discovered in the afterpeak and in two double-bottom fuel oil tanks located midships. The starboard propeller was reported non-operational. After refloating the vessel, an underwater survey revealed damage to the starboard rudder and bottom plating. As a result, classification society and Transport Canada inspectors determined that the vessel had to be repaired before it could continue its voyage. At the dry dock in the port of Qubec, the vessel was observed to have sustained extensive damage to the starboard rudder, both propellers, stern thruster No1, and the shell plating and adjacent internal structures. The starboard propeller hub was found to have sheared into two parts, and a void space in the bulbous bow section was also holed. All damaged parts were replaced, and shell plating that sustained indentations more than 10mm deep was cropped and renewed to restore the vessel to its original condition. As a result, the Certificate of Class remained valid without restrictions. Figure4. Typical section in way of rudder 1.7.3 Rudders Fitted with an Articulated Flap Unlike the steering and propulsion system of a conventional vessel, which has a single rudder and a single propeller, the NorwegianSky is equipped with a twin-rudder and twin-propeller system. To further enhance manoeuvrability of the vessel, the rudders are Becker design, semi-balanced, underhung units that incorporate a vertical, articulated flap in the after part of the rudder. When the helm is put over, the main rudder can be set at any angle up to 35(at sea) or 45(in harbour). Asthe main rudder rotates, the flap automatically articulates in the same direction, thereby increasing the maximum rudder angle. 1.7.4 Ship Handling When the pilots boarded the vessel, they were handed an extract of the Deck Procedures Manual, which included details of the ship and its propulsion, a navigation equipment checklist, the departure draught, and tidal information. The manual did not contain helm procedures for proceeding at speed in a restricted waterway. The turning circle of a ship is described by four numerical measures: advance (90), transfer (90), tactical diameter (180), and diameter of turning (360).9 Although these parameters may offer suitable measures to use in developing criteria and standards for different ships, they give little information on how much space a ship requires. The swept path is most useful for ship handlers when estimating potential clearance with waterways, other vessels, and obstructions. The maximum swept advance and swept transfer are greater than the ordinary advance and transfer.10 A pilot card was posted on the after bulkhead of the wheelhouse, behind the central integrated bridge system (IBS) workstations. The card indicated the use of hard-over helm at 35 and 45 for sea and harbour applications, respectively, and showed a swept-path diagram. However, the information was limited to the turning circle data and did not contain swept advance and transfer data with corresponding helm angles. Based on their experience, acquired during sea trials of the NorwegianSky, navigation personnel advised the pilots that 20 helm action was equivalent to hard-over helm and that 1or2 was sufficient helm action for most course alterations. Moreover, the master discouraged the use of hard-over helm. 1.8Bridge Layout and Navigation Equipment 1.8.1 Visibility from the Bridge Like most modern cruise liners, the NorwegianSky's wheelhouse is forward of the accommodation but a few decks below the uppermost deck. The navigation bridge is on the tenth deck above the waterline, at an elevation of 34.7m. Panoramic windows give exceptional forward visibility but, from the central navigation workstation, the field of vision abaft the beam is limited. 1.8.2 Integrated Bridge System On the bridge, on each side of the central navigation and manoeuvring workstation, is a communication workstation and a vessel monitoring workstation. On each side, outboard of these consoles is a chart table, and outboard again are the bridge wings. ISO Standard8468 covers ship bridge design and layout. An IBS enables the master and the pilot to monitor a radar and an ECS screen at the central navigation console. Figure7. Mimic presentation on ECS The master and the pilot occupied, respectively, the starboard and the port station at the IBS central workstation. For the most part, the master sat and the pilot stood. The OOW and the cadet used the inner starboard chart table for paper chart-plotting. The workstations are designed as an IBS unit. 1.8.3 Integrated Navigation System The central workstation display includes a radar and an ECS screen at each of the two work positions. Between these four screens is a conning information screen, with mimic presentation of all important conning, manoeuvring, and navigation information. Main engine controls are found on the centre counter between the two work positions. The INS enables a full range of navigation planning, steering, and collision-avoidance procedures to be carried out while also displaying own-ship reference to a geographical representation. The vessel's NACOS11 INS includes: three radar sets fitted with automatic radar-plotting aid capabilities, speedpilot and speed log control units,12 a helm autopilot, two gyrocompasses, a depth sounder and graph, a direction finder, a Loran C, a global marine distress and safety system (GMDSS), including INMARSAT B and C communication equipment, an ECS linked to a differential global positioning system (DGPS)13, monitors, linked to the INS, at the navigation console, the bridge wings, and the operations room abaft the wheelhouse. Gyrocompass error was deemed negligible. No equipment malfunction was reported. Abaft the wheelhouse are a control room and a radio room. Among other equipment in the control room are an automatic stability calculator linked to compartment and tank level sensors, various alarms systems, and an integrated video system. 1.8.4 Electronic Chart System The ECS on board was an ECDIS nautical planning and consulting station.14 This system enables the navigator to define and select a number of inclusion and exclusion zones, in which the computer will initiate automatic specific target tracking on the vector chart while defining channel limits and reducing operator workload. Important video and audio alarm signals can be selected to indicate if the vessel leaves these predetermined parameters. These alarms are easily recognized, even if the navigator is some distance away from the display. The radar image can be superimposed onto the ECS display. 1.8.5 Radars In addition to providing standard radar functions, each work station monitor is linked through the integrated radar display system. The pilots found that some buoys were difficult to detect on radar. Variable-range marker error was deemed negligible. 1.9 Bridge Resource Management The essence of bridge resource management (BRM) is effective utilization of all available human and physical resources to ensure safe operation. BRM addresses the management of attention, operational tasks, stress, attitudes, and risk. Optimizing the management of these elements has a direct effect on factors critical to the successful outcome of any operation. 1.9.1 Managing the Bridge Team Two interdependent teams were working on the bridge at the time of the occurrence. The helmsman worked closely with the pilot, who conducted the vessel under the master's supervision. The OOW and the cadet determined the vessel's position by chart work and updated the master. The chief officer, who was the most proficient user of ECS on board, was not on duty at the time of the occurrence. At 1156, after agreeing to extend the period of whale-watching, the bridge team did not alter its method of seeking and sharing navigational information. The pilots alternated their shifts while on board. Pilot No1 had conduct of the vessel upon departure at 0030 until 0655, and pilot No2 from 0655 until the occurrence. Pilot No1 had returned to the wheelhouse at the time of the grounding, but he did not assist the pilot (No2) on duty. During assignments on cruise liners, pilots take turns conducting the vessel. There is no procedure or contract requirement that calls for both pilots to be on active duty during whale-watching. In this region, the requirement for two pilots to conduct a vessel simultaneously is found only on tankers of 40000tonnes deadweight or more. 1.9.2 Managing the Navigation Equipment Each member of the bridge team had access to an IBS workstation and, as such, to the INS. Only navigation personnel used the integrated radar system; the pilot used a radar display that was independent of the integrated system used by the crew. The OOW and the cadet continued to follow on-board navigation practice, which called for frequent manual plotting to determine the vessel's position. The last position was plotted on the chart at 1200. The pilot's primary source of information was the radar using a north-up presentation. Targeting the Haut-fond Prince lighthouse as a radar cue, the variable-range marker set at 2nm indicated the safe distance off the Bancs de l'le Rouge which are 2.1nm from Haut-fond Prince. Neither navigation personnel nor the pilot applied the parallel indexing technique, using electronic bearing lines to assess the vessel's movement and position. The ECS was in operation for all bridge team members to use, but the team only glanced at the monitors. The system was equipped with the most recent electronic navigation vector charts issued by the distributor, CMAP, in1999. The pilots did, temporarily, overlay the radar presentation on the ECS presentation but found discrepancies in shoreline features and reverted back to single radar presentation using north-up presentation. Although standards have been developed for the ECDIS , carriage of this equipment was (and still is) not mandatory. Training standards for use of the equipment have also been developed, but training is not readily available. The DGPS receiver was set on the global positioning system (GPS) mode because navigation personnel found the positioning to be sufficiently accurate. The instrument on board is designed to select GPS by default unless specifically programmed to select DGPS mode. Navigation personnel were not aware of the high level of precision offered by DGPS reception in the area. 1.10 Communication 1.10.1 Ongoing Discussions Throughout the voyage, there had been ongoing discussions between pilot No1 and the staff captain and between pilot No2 and the master about navigation of the vessel. The senior staff shared with the two pilots their sea trial experience concerning the steering characteristics of the vessel. No communication, however, occurred between the pilot, the OOW, and the cadet. 1.10.2 Communication on the Decisions Taken During the voyage, navigation personnel were required to take action on several shipboard operations. Several times, this action required an exchange of information with the pilots on board, who had local expertise. Some of the key decisions made before the grounding were: At the beginning of the voyage, senior staff and the pilots agreed to carry out a whale-watching activity. At approximately 1153, the cruise director requested that time allocated to whale-watching be prolonged. It was decided to prolong this activity and not to proceed toward the pilot station. At approximately 1201, after being informed by the cadet that the vessel was nearing le Rouge, the master communicated his concern to the pilot. Given the response of the pilot, the master took for granted that all was under control and the turnaround manoeuvre was continued. According to the navigation personnel, at approximately 1203, the pilot ordered the helmsman to put the wheel hard-a-port. The master advised otherwise. The pilot repeated the order, and it was carried out. 1.11 Whale-Watching In the LPA district between Qubec and Les Escoumins, ClassA pilots are assigned the conduct of approximately 100vessels per year, but few assignments are related to a large passenger vessel. In 1999, 17passenger vessels made 55transits between the port of Qubec and LesEscoumins pilot station. In this pilotage district, a minimum of two licensed pilots is required on board passenger vessels longer than 100m. A ClassA pilot will thus be assigned an average of two such vessels per year. Passenger vessels in the St. Lawrence River often undertake some whale-watching. Out of 16assignments the naturalist carried out in1999, 14resulted in whale-watching. It is a featured attraction, normally lasting about one hour. Reportedly, few of these result in a turnaround manoeuvre to prolong the activity. This type of activity has taken place for the past 20years and has increased, with the flourishing passenger vessel industry, in the past 10 years. Since1980, the international cruise liner industry has increased at an annual rate of 4.7percent on the St.Lawrence River.15 The pilots discussed the voyage schedule with the crew. As requested by the navigation personnel, they planned to engage in whale-watching before proceeding toward the pilot station, but the plan did not include a turnaround manoeuvre. Whale-watching, with its requirement to manoeuvre, is at the master's discretion. The core activity of the Corporation des pilotes du Bas Saint-Laurent (the pilot corporation) is to provide a pilotage service and administration of revenues. The LPA is responsible for the safe operation of pilotage in its jurisdiction, continued proficiency training, and pilotage duties. Neither the LPA nor the pilot corporation had specifically addressed whale-watching before the occurrence. As such, visual and radar marks had not been planned or identified prior by the pilots for this type of manoeuvre. 1.12 Double Pilotage In December 1991, the LPA published its proposal to impose double pilotage on passenger ships in districts1 and2 of its region. Objections to the proposal by Canadian shipowners led to a September 1992 memorandum of understanding between the LPA and the Canadian Shipowners Association (CSA) whereby, among other topics, the question of double pilotage would be examined by appointed officials. In1992, LPA/CSA concluded that double pilotage for passenger vessels should be adopted and, in1993, the LPA set the requirement in place. Paragraph 35 of the LPA regulations stipulates that, for District2, two pilots are to be assigned to the following vessels: ships that are likely to be under way for more than 11consecutive hours in that district; ships of 74999tons deadweight or more; tankers of 40000tonnes deadweight or more; passenger ships longer than 100m; and ships during winter navigation. For long assignments (more than 11consecutive hours), each pilot will work a mutually agreed duration and will then be relieved by the other pilot. For large deadweight vessels, tankers, and passenger vessels, each pilot works alternately for most of the voyage, and a team approach is adopted for passage of hazardous, higher-risk areas. However, there are no written guidelines or work procedures that specify when or where two pilots should work as a team. Although passenger vessel assignments are rarely more than 11consecutive hours, pilots on these vessels work alternately and do not usually adopt a team approach for hazardous areas. In August 1998, the Minister of Transport requested that the Canadian Transportation Agency (CTA) carry out a comprehensive examination of pilotage matters to further safety, efficiency, and viability of the Canadian pilotage system. A review was undertaken, and its 21recommendations were published in September1999. According to the review panel, there was no indication that the 1992examination had performed a risk-based analysis to substantiate its conclusions concerning two pilots for passenger vessels. AppendixA: Track of the NorwegianSky Track of the NorwegianSkyrecorded by ECS on board (section of ENC chart CHS 1203) Appendix B: Photographs Photo3. NorwegianSky aground. Note current pushing the vessel against the Bancs de l'le Rouge Photo4. NorwegianSkyaground, Coast Guard Cutter IsleRouge assisting Photos on this page by permission of the Department of Fisheries and Oceans. Appendix C: Glossary 1. Units of measurement in this report conform to International Maritime Organization (IMO) standards or, where there is no such standard, are expressed in the International System (SI) of units. 2. See the glossary in AppendixC for all abbreviations. 3. All times are eastern daylight time (Coordinated Universal Time minus four hours) unless otherwise stated. 4. A splash door is similar in construction to a watertight door but only retards the flow of water from one compartment to another. 5. Code delta is the company's code to indicate to the crew a damage stability emergency procedure. 6. INS training enables an incumbent to better understand how different navigation systems work and interact with each other. 7. The Qubec-Les Escoumins Pilot Corporation. 8. Canadian Hydrographic Service, Sailing Directions: St. Lawrence River / le Verte to Qubec, 1999 (ATL111E). 9. The initial course followed by a vessel is 000. 10. Thomas G. Knierim, Maneuvring Information for the Pilot/Navigator: Its Source, Value, and Limitations, in Marine Technology, vol. 31, 02 April 1994, 123-144. 11. Atlas NACOS (NAvigation and COmmand System). 12. The Speedpilot is a component that sets automatically the speed according to a predefined ETA or alternately to maintain a constant speed. The speed log system has a display and control unit, and measures the speed over ground and/or through the water in both longitudinal and transverse directions. 13. At the time of the occurrence, the signal of the global positioning system was found to give optimum performance by not selecting the differential mode option. 14. The system was pending Electronic Chart Display and Information System (ECDIS) type approval. 15. Nicolas Tremblay, Ces palaces venus d'ailleurs, Entreprendre, 1997. 16. Integrating Computers into Navigation Control, International Maritime Technology, December 1994.